Contract reform: a change for the better?

Nigel Jones and a panel of professionals discuss the state of NHS dentistry and the impact contract reform may have…

It’s less than six months to go before contract reform is
due to begin being rolled out.

Since the original timeline of April 2020 was announced last
year, there has since been little decisive movement. This has led to feelings
of confusion and speculation among many that the date will be pushed back to
later in 2020, if not even further.

The lack of action will bring little comfort to the 93% of dentists with NHS involvement who believe it is important for the current NHS contract to change.

That’s according to the 2019 Dentistry Confidence Monitor
survey of NHS and private dentists held by Practice Plan.

Despite this widespread desire for change, there is an
equally prevalent view that the change that is being proposed through reform
will not be a positive one.

Only 4% of dentists with NHS involvement surveyed said they
thought the reformed contract would work well for the profession.

To discuss what these results mean for dentists and the
future of NHS dentistry, we held a discussion with key leaders within the
profession including Eddie Crouch, Bethany Rushworth, Simon Thackeray, Duncan
Thomas, Rory O’Connor and Chris Groombridge.

A pig in a ball gown

In a typically colourful analogy, Simon described the
reformed contract as a dressed-up pig.

“The NHS contract is a pig,” he said. “If you dress a pig
up in a ball gown or tuxedo and call it a new contract, it’s still a pig – and
that’s what we’re going to have.

“It might be more attractive initially, but it’s still a
pig.”

That paints quite an image, but on a serious note it does
encapsulate the feeling many have that contract reform simply won’t be an
improvement on the existing contract.

And given that 89% of dentists with NHS involvement are
unhappy/very unhappy with the current contract, that does not create a feeling
of optimism around the future for NHS dentistry.

The need for action

Eddie said, “Something has got to happen urgently, and
there are other ideas in the pipeline such as flexible commissioning or some
kind of transitional arrangement that will give some stability back to NHS
practices that are on the brink.

“Delaying the introduction of a reformed contract is fine
to get it right, as long as something else happens. And something else has to
happen because otherwise the whole system will come crumbling down.”

Duncan, who recently removed his practice from the
prototype programme, said, “Contract reform is not a panacea.

“The latest I have heard about the reformed contract is
that there will be a move towards a capitated system based upon deprivation and
age of the patient.

“The problem with that is that it’s not the system that is
being prototyped at the moment.

“So, the drivers behind the contract aren’t being modelled.
They might be being modelled at a statistical level by the Government behind
the scenes but it’s not what’s driving practices that are delivering the
contract through the prototype programme.”

Resilience training for students

The panellists discussed how the uncertainty around the
reformed contract and the way it is due to be rolled out is taking place amid a
backdrop of dentists working in an increasingly pressurised environment.

They talked about increased expectations from patients,
regulatory burdens, the risk of litigation, financial strain and the feeling of
needing to do more with less.

Indeed, Eddie highlighted that the pressures are such that some
dental students are now receiving resilience training at university.

To which Rory responded, “The need for resilience training
is symptomatic of modern-day slavery, because the expectation is that you must
give more for less.”

The results of the Dentistry Confidence Monitor survey
suggest many feel reform won’t improve that feeling of pressure. The majority
of dentists with NHS involvement say they think it will increase their workload
and decrease their profitability.

Rory suggested that more ‘togetherness’ among the
profession and a united voice would help to drive the positive changes that so
many want to see.

“The results of the Dentistry Confidence Monitor survey suggest many feel reform won’t improve that feeling of pressure. The majority of dentists with NHS involvement say they think it will increase their workload and decrease their profitability. “

He said, “Togetherness includes the GDC, the BDA, social
media groups and anyone in the profession who has a reasonable voice, to get
together and stand together to have enough power to challenge the Government.”

Eddie said, “We have a voice, what we don’t have is ears on
the other side.”

The Health Select Committee

There was debate about whether the Health Select
Committee’s (HSC) recently opened review of NHS dentistry could be a driver for
change.

Chris said, “The HSC in 2008 was damning on the current
contract and said it wasn’t fit for purpose. I’m hoping in the current climate
where we have a small government majority, that this could make somebody sit up
and take notice.

“Personally, I think that only if access is affected will
the Government take notice because that is what starts to fill up MP’s
postbags.

“But hopefully the HSC will highlight the big issues and
say ‘you can’t keep ignoring them anymore, stop trying to bury them’ and then
we can have a realistic sensible conversation about finding a solution.”

Bethany added, “It isn’t a priority at the moment for
government because their perception is that there’s currently enough dentists
to replace those who are unhappy.

“So, despite what we know to be the reality, they’re happy
for dentists to leave the NHS or move to private practice because they think
they can still provide access to dental care.

“Dentists’ opinions on contract reform won’t really be
addressed until it’s too late. While reform probably isn’t in the best interest
of dentists it doesn’t seem like anyone cares as long as it’s financially
benefitting the Government and patients aren’t noticing an affect to their
access to care just yet.”

The survey results suggest that the perception of there
being a ready supply of dentists willing to deliver NHS dentistry might be wide
of the mark.

Seventy-seven per cent of predominantly NHS dentists said
they do not see themselves operating in the NHS in five years’ time.

And, only 46% planned on staying in dentistry at all – by
moving to private – with the rest indicating they would retire (either as
planned or earlier than planned) or change profession entirely.

Anxiety and the diet of fear

Rory said that the desire to leave their job was a common
theme among the calls he takes from dentists struggling with their mental
health.

He said, “Pretty much everybody starts off saying ‘how can
I leave?’

“I always begin the conversation by saying that now is
probably not the time to make that decision, they need to look at getting well
before they even start to think about things like that.

“The most common presentation of people coming to the
service is anxiety, depression and addictive disorders. We can help people
understand what that is but behind that is understanding what the trigger is
for it and quite often work plays a high part.

“Anxiety is the diet of fear and within that there are
menus of rumination and anticipation about what I’ve done and what’s going to
happen.

“One of the primary drivers within anxiety in the dentist
is the fear of dentistry – what have I done and then you get into over-checking,
etc, and then what might I do. Which is why we delay them thinking about
leaving the profession because we might be able to help them practise in a
different way and address it in a different way.”

The mental health of the profession was a recurring theme
throughout the discussion, which may be a reflection of how important the topic
is becoming as well as the growing awareness of just how big a challenge it is.

“One of the primary drivers within anxiety in the dentist is the fear of dentistry”

Practice Plan will be sharing more details of that wider
discussion, which also included the GDC, the culture of the NHS and mindset of
the profession, and the education of dental students, in future articles, blogs
and videos.

Dentists who want to learn more about contract reform and
the impact it may have on them are invited to attend free panel discussion
events, all of which include Eddie.

The What Next for NHS Dentistry? events take place on November
20th in Chelmsford and November 27th in Nottingham.

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